Gov. Sandoval and Obamacare: What a long, strange trip it's been

Nevada Health Link would like to thank each family, individual and small business that has signed up for health insurance. We will be mailing out enrollment information very soon.”

---Tweet from Nevada’s Obamacare exchange, 11/20/13

“The very real and harmful consequences of this ill-conceived law are now being experienced by not just Nevadans, but people throughout the country. “

----Gov. Brian Sandoval, the same day

Nevada Health Link is Brian Sandoval. Brian Sandoval is Nevada Health Link.

It was his idea. He argued for money to fund it. He owns it.

So there is no better example of Nevada’s need for better mental health care treatment than the state’s highest profile elected official’s Obamacare personality disorder. Someone find the governor a bed at Rawson-Neal so he can get this ailment cured!

As much as I am enjoying the spectacle of our usually stolid governor suddenly getting animated about the Affordable Care Act as his state health exchange boss enthuses about the coming successes of people getting enrolled, awkwardness does not always equate to hypocrisy. Issues are never as one dimensional as campaign operatives and extreme partisans conjure them to be.

So what's the truth?

Sandoval always has opposed the law, going back to his campaign for governor. But he has said very little about it in his return to Nevada politics from the federal bench, and as governor he has implemented two key parts of the law that other governors have not – erecting an exchange and expanding Medicaid. Although he has defended both, one as trying to loose federal tethers and the other as a potential economic booster (forget any argument that covering the poor is a good policy), Sandoval's rhetorical peregrinations through the last three years or so are worth revisiting.

This might become a political problem for Sandoval if there were any such thing as a political problem for Sandoval. All such analyses must be seen through the prism of the inability of Democrats to field a candidate and the prospects of a serious primary challenge evanescent at best. It may become an issue for him in the lieutenant governor's race, as Sue Lowden has signaled she plans to use it, which may force Sandoval to engage.

I wouldn't say he's worried. But the preternaturally careful governor – does he even step on the cracks in the sidewalk near the Capitol? – clearly has been reading polls or had an epiphany recently as his news release numbers on Obamacare during the last week equal his previous output on the subject for his tenure.


When Sandoval was running against Gov. Jim Gibbons, one of their rare points of agreement was the state’s lawsuit against the federal government over the Affordable Care Act. During a debate a week before the election, as the Review-Journal reported, “Sandoval promised to continue the state's lawsuit seeking to block the law from taking effect.”

And he did, saying later he believed the individual mandate was unconstitutional and telling his state-appointed lawyer Mark Hutchison, now his chosen candidate for lieutenant governor, he was envious. “Sandoval told me if he wasn't so busy, he would love to come argue the case with me," Hutchison told the RJ a month after Sandoval was elected.

In late January 2011, when a federal judge in Florida agreed with Nevada and other states suing the feds, Sandoval put out the first of his four Obamacare news releases, saying in part: 

I have noted my concerns that the federal health care legislation has serious constitutional questions which need to be answered by the courts. Time is of the essence in settling this issue because we are being forced to implement portions of this law. As Nevada is a party to this lawsuit, I look forward to its continuation.

So, color him happy. As for being forced to implement any part of the law, the governor did not have to set up an exchange or expand Medicaid. Those he would choose to do all on his own.

Sandoval briefly addressed Obamacare in his first State of the State in 2011, repeating that he believed “many aspects of the law are unconstitutional" and:

I will continue to fight to have them overturned. In the meantime, however, the law imposes many deadlines, and we cannot wait until litigation is resolved. We must plan for a major expansion of Medicaid, which may cost Nevadans $574 million between 2014 and 2019. We must also plan for a Health Insurance Exchange so that we – and not the federal government – control the program. My budget includes funding to address these issues, and I have submitted legislation to address the operation and oversight of a Nevada Health Insurance Exchange.

So his argument for spending millions to set up his own exchange, rather than the path other governors took to not do so and hope the federal one tanked, was for control. Period.


The governor was silent on the law for nearly 18 months until the U.S. Supreme Court upheld the law. After boilerplate stuff about us being a nation of laws and his abiding love for Jefferson & Co., he added:

The implications for Medicaid costs are still unclear, but Nevada will prepare to meet the serious financial implications of this decision. I believe the Congress should act to reform this law and ease the serious burdens it places on the states and the nation’s businesses. The American people remain deeply divided on the wisdom of this law and they are still entitled to see it changed.

You could infer from that statement that he was leaning against expanding Medicaid, and he would later tell Sam Shad of "Nevada Newsmakers" that he indeed was inclined not to cover the 78,000 Nevadans who would benefit. It always seemed to me during the next six months that his estimable HHS chief, Mike Willden, wanted to do so, especially because of the penurious approach the state takes toward covering the poor.


And then in December, the governor made his announcement in a Sandovalian exemplar of a news release, becoming the first Republican governor to commit the apostasy and indicating he still hated the law, would lessen the burden on businesses (even though the expansion would make the state money), would reserve the right to change his mind if anything changed and would charge Medicaid patients a co-pay!

Though I have never liked the Affordable Care Act because of the individual mandate it places on citizens, the increased burden on businesses and concerns about access to health care, the law has been upheld by the Supreme Court. As such, I am forced to accept it as today’s reality and I have decided to expand Nevada’s Medicaid coverage.

My fiscal year 2014-2015 budget will provide 78,000 additional Nevadans with health insurance coverage through Medicaid, which is estimated to save the state general fund approximately $17 million dollars in mental health savings. My executive budget will also help Nevada businesses cope with the burden placed on them by decreasing the modified business tax. My decision to opt-in assists the neediest Nevadans and helps some avoid paying a health-care tax penalty. As part of my proposal, I will also call upon the Legislature to pass Medicaid patient responsibility cost-sharing measures.

I will commit to working with the Legislature if anything changes at the federal level. At any point during the Legislative session, if there is any sign of change at the state or federal level, it may alter my support for expansion.

Has anything changed at the federal level?

Sandoval addressed Obamacare again in his State of the State earlier this year, in which he almost seemed to brag about being able to cover those 78,000 needy folks but insisted on playing the decision as budget-saving and job-creating:

As a result, some 78,000 more Nevadans will now have coverage – without facing the new tax penalties imposed by the Affordable Care Act. The federal law allows us to shift mental health and other state spending to Medicaid sources, saving the General Fund nearly 25 million dollars over the biennium. Over the next 6 years, this comprehensive approach will create up to 8,000 new health care jobs and inject over half a billion dollars into our state’s economy. And, as I’ve noted before, we must reduce taxes so businesses can to help them bear the increased costs of the Affordable Care Act.

But, the issue of long-term health care costs remain. As such, I believe we must ask certain Medicaid patients to make a modest contribution toward the cost of their own care. And I will insist that Nevada be able to opt-out of the Medicaid expansion program in future years, should circumstances change.

Should circumstances change? It’s free for quite some time. So you are going to cover people, then un-cover them when the state has to pay more?

State lawmakers enacted all of the Obamacare implementation bills Sandoval proposed. None of the votes were even close.


And note no fulminations in there about the ACA. Indeed, he wouldn’t speak much about Obamacare until May when he submitted to an interview with national reporter David Drucker. In the conversation, Sandoval bragged about how well his exchange was doing while completely dodging a question about repealing the law:

Our Nevada exchange — and I think if you read some of the print on it, or the media — is that it has been a national leader in terms of being a model for other state-run exchanges. And my understanding, anecdotally, is that the [Centers for Medicare and Medicaid Services] has reached out to us in terms of how we are implementing things because we were one of the first ones out and because of that, we’ve had to basically forge our own course, we’re pioneers with regard to that. … To respond to your question, it’s been frustrating, in terms of trying to get the information so that we can get to decision points and move forward.

Q. Will the Affordable Care Act benefit Nevadans? Or is it that you’d rather the law not exist, but being that it does, you’re going to do the best job you can? How is the statute going to shake out for your average Nevadan who either gets their insurance through their employer or buys a plan on the open market?

A. Stepping back a bit, Nevada was a party to the lawsuit that was in front of the U.S. Supreme Court. As you say, the Supreme Court made its decision, and the [2012] election is what it is and so there isn’t going to be a change and we’re going to push forward. It’s hard to respond specifically to your question because we don’t have the specificity from the federal government. But at the end of the day, obviously I wouldn’t have [chosen to implement the Nevada exchange] if I didn’t think it could be helpful to the people of Nevada.

Q. Republicans keep trying to repeal the law. If after 2016, you ended up with a Republican Senate and a Republican House and a Republican president and they could actually get rid of the law, or most of it, and replace it with the kind of reforms Republicans like, would you rather see that happen?

A. That’s a huge hypothetical. But, yes, certainly, any type of health care reform that can be accomplished. But we’re talking three years down the line. … But anywhere where we can have reform and save taxpayer money and improve the delivery of care is something I’d obviously be for.

Q. Do you favor the repeal of Obamacare? Or, all things considered, just leave it alone and try to focus on making it work?

A. Well there are a lot of moving parts there, and as I said, I’m a governor that has to govern now with the law as it stands now and that’s how we’re going to proceed, but if there’s a change in the law, we’ll look at it at that time.

Got that? So here’s where we were in May: Sandoval still hates the law, but the court acted and Barack Obama won, so we are going forward with our GREAT Nevada exchange and I will do anything I have to do not to answer a repeal question.


Sandoval didn’t say much of anything on Obamacare as the furor grew in DC. That is, until last Friday, the same day the president announced his “fix” to allow insurance companies to extend policies. Then his apparently simmering outrage could not be contained, especially as poll numbers started to indicate that Obamacare was THE issue for the GOP  in 2014:

I opposed Obamacare from its inception.  However, when the U.S. Supreme Court upheld it, every state and every American was forced to abide by it. As a state, Nevada’s only choice was whether to let the federal government control the process or manage the process ourselves.  We rightly opted for the latter.  Now, despite our best efforts to comply with this ill-conceived law, the failure at the federal level has made this effort in Nevada significantly more difficult or even impossible.

Without a doubt, the President’s actions this week are a direct acknowledgement that the law is unworkable. What’s more, the announcement yesterday does not fix any problems and only adds more confusion. I strongly urge the President and Congress to reconsider this law.

Or impossible?

This comes as Jon hager, the head of Nevada Health Link, the governor’s exchange, has done a round of interviews, including on "Ralston Reports" last week, and appeared before a legislative committee Thursday, telling everyone who will listen that the federal exchange does not affect the Nevada analogue and that the state apparatus is doing well.

Impossible? Not so much.

That was not enough, though. Unprompted, except perhaps by poll results and room on the bandwagon, Sandoval let loose again Wednesday with an uncharacteristically harsh broadside:

The fact is the President misled the American people when he promised they could keep their insurance if they liked it.  His statements last week did nothing to remove the Obamacare mandates that have resulted in cancelled insurance policies.  Furthermore, those in Congress who supported this law should have known that implementing these mandates would result in cancelled policies.  The very real and harmful consequences of this ill-conceived law are now being experienced by not just Nevadans, but people throughout the country. 

The only way to fix the problems resulting from this law is to change the law itself.  So, I again call upon the President and Congress to act swiftly.  I firmly believe Obamacare must be dramatically changed or repealed.

So now he’s Louis Renault, and now he can answer Drucker’s question? It is much easier to be forceful when the political winds shift so obviously, right?

Maybe that’s a bit unfair, just as unfair as any of the governor's political enemies implying he has not consistently opposed the law. He has.

But Sandoval also has done what few other Republican governors have done, which is to expand Medicaid and build an exchange. He can't hide from that, either.

Nevada Health Link is Brian Sandoval’s now. He might as well own it or see if that Rawson-Neal bed is free to treat his Obamacare personality disorder.